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Course Description:
While meditation practice is generally safe and has beneficial results, it can catalyze challenging psychological problems. It can also be misused by meditators in ways that undercut the goals of psychotherapy. In addition, there are psychological conditions where meditation practice is contraindicated or should only be used with caution. This course explores these considerations in using meditation in clinical practice.

While meditation practices, and particularly mindfulness forms of meditation, are generally safe and have overwhelmingly beneficial results, they can catalyze challenging psychological problems. they can also be misused by meditators in ways that are contrary to the goals of psychotherapy. In addition, there are psychological conditions where meditation practices, again inlcuding mindfulness, are contraindicated or should only be used with great caution. This lesson will explore those potentially problematic aspects of mindfulness practice in a general way that includes other forms of meditation as well. Where the term ‘meditation’ is used below the reader can assume that the issues being discussed apply to mindfulness as a form of meditation unless specifically stated otherwise.

Meditation Related Psychological Problems

In the course of meditation practice, meditators sometimes encounter experiences that are especially challenging and that catalyze personal crises of various kinds and degrees. Such crises span the spectrum from spiritual emergence to spiritual emergency, terms first used by Stanislav and Christina Grof. When in the midst of spiritual emergence, the practitioner is opening to types of spiritual experience both that are new to them and which may be temporarily disorienting. A spiritual emergency can be said to occur when spiritual openings become so disorienting as to manifest, at least temporarily, as a loss of the client’s ability to function normally in various everyday contexts. Especially when the degree of disorientation affects normal functioning, the symptoms fall within theDSM IV category of Religious or Spiritual Problem (V62.89) as a spiritual problem.

The existence of problems associated with meditation is not limited to their psychological use. Such problems are acknowledged in spiritual traditions, as well. For example, Mark Epstein (2007: Psychotherapy without the Self: A Buddhist perspective) describes a "specific mental disorder that the Tibetans call 'sokrlung':

a disorder of the 'life-bearing wind that supports the mind' that can arise as a consequence...of strain[ing] too tightly in an obsessive way to achieve moment-to-moment awareness. (p. 85)

When Asian meditative practices are transplanted into Western contexts, whether spiritual or psychological, the same problems can occur. Anxiety, dissociation, depersonalization, altered perceptions, agitation, and muscular tension have been observed in western meditation practitioners. Yet Walsh and Roche (1979—link below) point out that "such changes are not necessarily pathologic and may reflect in part a heightened sensitivity" (p. 1086). The DSM-IV-TR emphasizes the need to distinguish between psychopathology and meditation-related experiences. For example, voluntarily induced experiences of depersonalization or derealization form part of meditative and trance practices that are prevalent in many religions and cultures and should not be confused with Depersonalization Disorder. (p. 488)

Nonetheless a significant number of Western practitioners have reported adverse effects. Shapiro (1992) surveyed 27 meditators with an average of nearly 5 years of practice including some experience of silent meditation retreats. While this group reported many more positive than negative effects, 62.9% of the participants mentioned experiencing at least one adverse effect during and after meditation, while 2 subjects reported profoundly adverse effects. The negative effects reported included relaxation-induced anxiety and panic; paradoxical increases in tension; less motivation in life; boredom; pain; impaired reality testing; confusion and disorientation; feeling 'spaced out'; depression; increased negativity; being more judgmental; and, ironically, feeling addicted to meditation. The following 4 articles all address Meditation Related Psychological Problems:

The spiritual literature is rich with descriptions of similar experiences depicted as normal, even necessary stages along the path of spiritual development, sometimes referred to with evocative terms, such as “Dark Night of the Soul.”Such experiences are even described in a positive manner in some schools of psychology, such as Carl Jung’s use of the alchemical metaphor, which includes the stage of the nigredo, a parallel to the Dark Night of the Soul.

Since such problems can present in clinical contexts with symptoms similar to forms of psychosis or anxiety disorders, spiritual assessment and differential diagnosis skills are essential for clinicians working with these cases to insure that appropriate treatment is provided. When working with a client going through a meditation-related problem, it is often advisable, with the client’s permission, to consult with the teacher who has been guiding their spiritual practice. See the course entitled “DSM-IV Religious & Spiritual Problem” for more detailed information about the assessment, differential diagnosis, and treatment options for meditation-related and other forms of spiritual emergence/emergency problems.

In addition to eliciting spiritual crises, meditation, especially in the context of intensive silent retreat practice, has been known to catalyze the onset or relapse of serious psychological crises or disorders. The following article reports on three such cases.

Some meditation centers have developed protocols for screening participants for psychological issues for which their programs are contraindicated. Such protocols also generally include procedures for identifying psychological emergencies on retreat and referring to appropriate mental health services.

Misuses of Meditation

Meditation, along with other spiritual practices, can also be used as a psychological defense mechanism against difficult emotions, memories, or life situations, presenting a thorny challenge for the psychotherapist. Such a misuse of meditation falls in the category of “spiritual bypass,” a term coined by psychiatrist Charles Whitfield to describe how some people use their spiritual practice as a way to avoid dealing with and taking responsibility for their feelings. A person who immediately goes to meditate whenever a difficult or painful feeling comes up in the hopes of blissing out to avoid the feeling may considered to be engaging in spiritual bypass. They are substituting meditation for the unavoidable suffering of the human condition and the painful struggle to achieve a stable sense of identity and meaningful relationships with others. For more on the phenomena of spiritual bypass, see the following piece by Robert Augustus Masters, an integral psychotherapist.

Contraindications

There are psychological conditions and situations when meditation, including mindfulness, is contraindicated. A useful rule of thumb is that meditation should be used with caution whenever there are concerns regarding reality testing, ego boundaries, lack of empathy, or rigid over-control. Jack Engler, psychologist, meditation teacher, and author believes that Buddhist meditation, especially mindfulness, and Western psychotherapy work together to liberate different levels of self that make up a human being. He is also credited with pointing out that, “you have to become somebody before you can become nobody” to suggest that one needs to have developed a coherent sense of oneself and relatively healthy object relations before attempting to attain a deeper understanding of reality or of one’s true nature through meditation. (Do You Really Have to be Somebody Before You Can be Nobody?--An interview with Jack Engler) Engler also notes that people with narcissistic or borderline character structures may attempt to use meditation to make themselves “pure” or to reframe feelings of emptiness and fragmentation as the “voidness” or “selflessness” of enlightenment. These people want enlightenment only on their terms. Such attempts to shortcut healing can be dangerous and are likely to end in failure. In others, it can exacerbate obsessive and schizoid traits.

Since meditation, especially mindfulness, can be a powerful tool for self-reflection, it can occasionally produce an opening to inner dimensions of experience that could be overwhelming to psychologically fragile individuals. In addition, relaxation-induced anxiety, where an individual unaccustomed to deep relaxation that often accompanies meditation and finds the resulting physiological release and attention to internal sensations, perceptions, and images to be a source of fearful anxiety-producing apprehension, can occur. Meditation must be carefully considered in therapy and evaluated with attention to the psychological status of the patient.

Besides the general contraindications and cautions mentioned above (i.e., those associated with deficient reality testing, porous (fragile) ego boundaries, pathological deficiency in empathy, rigid self-control), there may be specific contraindications for particular styles of meditation. For example, concentration meditation involves an inner collectedness of psychic energy and therefore may be more prone to induce dissociative states or exacerbate dissociative tendencies, while mindfulness meditation, with its emphasis on insight and self-awareness may be more likely to evoke repressed emotions or memories. Unfortunately there is little published scientific research specifically studying the negative side effects of meditation. The following survey of the research articles through the year 2000 includes a section on the negative side-effects of meditation: Perez-De-Albeniz A and Holmes J (2000). “Meditation: Concepts, Effects and Uses in Therapy.” International Journal of Psychotherapy 5(1): 49-58. Below is another more recent article focusing on safety issues encountered in research specifically on mindfulness meditation that are parallel to those which need to be addressed in clinical practice: Lustyk MK, Chawla N, Nolan RS, Marlatt GA. (2009). “Mindfulness Meditation Research: Issues of Participant Screening, Safety Procedures, and Researcher Training.” Adv Mind Body Med. 24(1): 20-30.

Meditation is always contraindicated for populations with a DSM IV-TR Axis I or Axis II disorders.

TrueFalse

Relaxation-induced anxiety can occur where an individual unaccustomed to deep relaxation that finds the resulting physiological release and attention to internal sensations, perceptions, and images, to be a source of fearful anxiety-producing apprehension.

TrueFalse

The “Dark Night of the Soul” is a form of spiritual bypass.

TrueFalse

When Asian meditative practices are transplanted into Western contexts, the same problems observed in these traditions can occur.

TrueFalse

According to Shapiro (1992), only a small percentage of individuals ever report any adverse effects during and after meditation.

TrueFalse

Concentration meditation is more likely to evoke repressed emotions or memories than mindfulness meditation.